none mild moderate-severe...ga wks 9.8 13.6 33.9 0 25 50 none mild moderate-severe o2 > 1 hg – rop...
TRANSCRIPT
-
4/23/2015
1
OXYGEN TARGETS: HOW GOOD ARE WE IN ACHIEVING THEM
Eduardo Bancalari MD
University of Miami Miller School of Medicine
Jackson Memorial Medical Center
CARE OF THE SICK NEWBORN 2015
Infants born at UM-JMH, GA 24-31w Years 2008-2009
Postnatal age (weeks)
Oxygen Dependency
GA wks
9.813.6
33.9
0
25
50
NONE MILD MODERATE-SEVERE
Hrs
TcP
O2
> 8
0 n
nH
g
(week
s 1
– 4
)
ROP Severity (N= 101)
Flynn J, Bancalari E, NEJM 1992
Progression to Threshold
Conventional
Sat 89-94%
Supplemental
Sat 96-99%
ALL 48% 41%
OR 0.72 (0.52 – 1.01)
Non plus
disease 46% 32%
STOP – ROP The STOP-ROP Multicenter Study Group: Pediatrics 105:295, 2000 STOP – ROP
The STOP-ROP Multicenter Study Group: Pediatrics 105:295, 2000 Conventional Supplemental
Pneumonia or Pulmonary
Deterioration
8.5%
13.2%
Hospitalized at 50 wks PMA 6.8% 12.7%
On Oxygen at 50 wks PMA 37.0% 46.8%
On Diuretics at 50 wks PMA 24.4% 35.8%
-
4/23/2015
2
358 infants enrolled at 32 weeks PMA
Saturation targets: 91-94 vs 95-98
OUTCOME Standard
Saturation
N=178 Bwt
918g
High
Saturation
N=180 Bwt
916g
P
BPD (O2 at 36 weeks PMA)
(%)
82 (46) 116 (64)
-
4/23/2015
3
Distribution pattern, time, and age dependency of
hyperoxia-induced apoptosis in infant rats
Felderhoff-Mueser, U et al. Neurobiol Disease 2004; 17(2): 273-282
Multivariate odds ratios for DCP with 95% CI and
test of significance for risk factors
From Collins, MP et al. Ped Res 2001; 50(6): 712-719
Risk factor Model 1* (N=400) Model 2* (N=400) Model 3* (N=390) Model 4* (N=336)
Cumulative hypocapnia 2.9 (1.6, 5.5)
p= 0.001
2.2 (1.1, 4.5)
p= 0.03
2.2 (1.0, 4.7)
p= 0.04
2.6 (1.1, 6.4)
p= 0.03
Cumulative hyperoxemia 2.5 (1.3, 5.1)
p= 0.01
2.4 (1.1, 5.2)
p= 0.02
2.1 (0.9, 5.0)
p= 0.10
Prolonged ventilation 2.9 (1.5, 5.6)
p= 0.002
2.3 (0.9, 5.9)
p= 0.09
3.0 (1.0, 8.9)
p= 0.04
Gestational age 0.9 (0.6, 1.5)
p=0.83
0.9 (0.7, 1.5)
p= 0.59
Odds Ratio
0.1 1 10
Term
Preterm
Apgar score 1 min 1,000g) and the most depressed infants
(1-min Apgar
-
4/23/2015
4
Optimal oxygenation of ELBW infants: A meta-analysis and systematic review of the oxygen saturation target studies
BPD
Saugstad OD and Aune D. Neonatology 2014; 105: 55-63.
Optimal oxygenation of ELBW infants: A meta-analysis and systematic review of the oxygen saturation target studies
NEC
Saugstad OD and Aune D. Neonatology 2014; 105: 55-63.
Optimal oxygenation of ELBW infants: A meta-analysis and systematic review of the oxygen saturation target studies
Mortality
Saugstad OD and Aune D. Neonatology 2014; 105: 55-63.
How good are we keeping
oxygen targets?
Achieved Versus Intended Pulse Oximeter
Saturation in Infants Born Less Than 28wks
The AVIOx Study
14 Centers using different saturation targets
Percent time
Below target 16 (0-47)
Within target 48 (6-75)
Above target 36 (5-90)
Hagadorn et al. Pediatrics 2006
Higher vs. Lower Arterial Oxygen Saturations in Extremely Preterm Infants
Schmidt B et al. JAMA 2013; 309: 2111-2120.
-
4/23/2015
5
Why are we so bad in keeping oxygen
targets?
Blood oxygen level fluctuates constantly: Require
continuous attendance and tight alarm settings
Delayed response:
Desensitization to frequent alarms
Lack of buy-in by staff, unknown
consequences of transient deviations
More concern with hypoxemia than hyperoxemia
Response not always appropriate for the mechanism of
the hypoxemia
Sp
O2
FiO
2
Claure et al. J Pediatr 2009
Nurse: patient ratio and achievement of oxygen saturation goals in premature infants
Sink DW, et al. Arch Dis Child Fetal Neonatal Ed (2010). Online First doi:10.1136/F2 of 6 adc.2009.178616
PaO2 vs. SpO2
Castillo et al,
Pediatrics 2008
Quine et al,
ADC FN Ed 2008
Develop clear unit guidelines for oxygen monitoring and targets
Set alarms on target range
Minimize factors that induce fluctuations in
oxygenation
Continuous education of medical and nursing personnel
Proper nurse patient ratio
Monitor incidence of pathologies associated with
hyperoxia
Automated systems for oxygen control
How can maintenance of oxygen
targets be improved? % time within target
Cl. loop Manual Type
Beddis, 1979
Dugdale, 1988
Bhutani, 1992
Morozoff, 1992
Morozoff, 1993
Sun, 1997
Claure, 2001
Urschitz, 2004
Morozoff, 2009
Claure, 2009
Claure, 2011
Efficacy of Automated FiO2 Control
-
4/23/2015
6
The University of Miami, Drs. Claure and Bancalari
have a patent on the algorithm for automated
adjustment of inspired oxygen and a licensing
agreement with Carefusion
Clio studies have been supported by Carefusion
Disclosure
*:p 93% (@O2>21%)
> 98% (@O2>21%)
< 87% < 75%
*
*
*
* *
% o
f 24 h
ou
rs
Claure et al. PAS 2009
Prolonged episodes with SpO2 below intended range
SpO2 < 85% (>120s)
*:p60s)
Standard
Automated
Workload:FiO2 adjustments
*:p
-
4/23/2015
7
Oxygenation Targets:
Can they be achieved?
Arterial oxygen levels fluctuate constantly in preterm infants and maintenance of targets is a tedious and
demanding task
Fluctuations can be produced by different mechanisms
that require specific interventions
While hypoxemic episodes are usually related to patient
issues, hyperoxemia is always induced by excessive
inspired oxygen
Infants are seldom hyperoxic on room air
Need to define the best targets and the short and long
term consequences of fluctuations in oxygenation
Surely can do better with
oxygen targets, but…
Avoid hyperoxemia: Keep PaO2 40mmHg
SpO2 over 88-90%
Keep higher SpO2 in infants with ROP or BPD?
Keep in mind limitations of SpO2 in predicting PaO2
What oxygen targets should we
use?